Concussion Update: Review of 5th International Conference on Concussion in Sport in Berlin October 2016 April 28, 2017

HEADLINE, ARIAL BLACK ALL CAPS – CENTERED

Background 1st meeting Vienna 2001. Started as a group of professionals IIHF, IOC, and FIFA IRB added to 2nd meeting Prague 2004 3rd and 4th meetings Zurich 2008 and 2012. Participants chosen to create a broad-based non- government, non-advocacy panel from researchers in clinical medicine, sports medicine, neuroscience, neuroimaging, athletic training and sports science.

Changes in Berlin to prior guidelines Document is divided into 11 sections: 11 R’s of concussion-Recognize; Remove; Re- evaluate; Rest; Rehabilitation; Refer; Recover; Return to sport; Reconsider; Residual effects and sequelae; Risk reduction One of the standout features of the Berlin CISG meeting was the engagement by experts from the TBI, dementia, imaging and biomarker world in the process and as coauthors of the systematic reviews

Recognize Definition SRC: part of TBI spectrum with structural change or result of reversible physiologic change Role of technology measuring head impact is not well defined as variable results in current studies SCAT 5 is most well established rigorously developed tool for sideline assessment. Most useful “immediately” after injury (less useful 3-5 days after injury). Baseline not necessary Symptom checklist has utility immediately and for tracking follow up If baseline SCAT 5 is used, testing environment should be similar for suspected acute concussion evaluation

Recognize Other useful sideline assessment tools include clinical reaction time, gait/balance assessment, video-observable signs and oculomotor screening. Serial evaluation process for suspected concussion recommended to identify the delayed onset SRC individuals Comprehensive evaluation involves review of 6 clinical domains for abnormalities from baseline

Recognize: Clinical Domains Somatic, cognitive or emotional symptoms Physical signs (LOC, amnesia, neuro deficit) Balance impairment Behavioral changes (reaction time) Cognitive impairment Sleep/wake disturbance

Remove Once SRC is diagnosed, player should be removed from continued participation Final determination of diagnosis of SRC and disposition (RTP) is a medical decision based on clinical judgment

Re-evaluate This is opportunity for comprehensive history and detailed neurological exam (including mental status/cognition, oculomotor function, gross sensorimotor, coordination, gait, vestibular function and balance) Assess whether clinical status of athlete is improving or deteriorating Assess whether emergent care/referral is warranted (need for imaging, etc) Neuropsychological assessment (aids decision making but not sole basis for medical decision making) Advanced neuroimaging, fluid biomarkers and genetic testing are important research tools only Computer based NP testing is widely used due to wide availability and limited availability of qualified neuropsychologists in this setting. Not equivalent to complete NP assessment.

Rest Acute phase (<48 hrs) physical and cognitive rest to ease discomfort and promote recovery by minimizing energy demands on brain. After 48 hrs, should be encouraged to become gradually and progressively more active as symptoms allow

Rehabilitation SRC can result in diverse symptoms and problems and treatment should be individualized as needed. Treatment considerations include directed care of concurrent C-spine injury, disruption in vestibular system, and psychological issues. Monitored active rehab programs with controlled sub-symptom threshold sub maximal exercise has shown benefit

Refer Persistent symptoms: failure of normal clinical recovery in timeframe expected (10-14 days adults, 4 weeks in children) Treatment individualized and target specific medical, physical and psychosocial factors Treatment should be multidisciplinary and collaborative and may include: symptom limited exercise program, formal PT, CBT, pharmacotherapy

Recover Large majority of athletes recover from a clinical perspective within a month from date of injury. Strongest and most consistent indicator of slower recovery is severity of initial symptoms Development of sub acute migraine or depression are likely risk factors for persistent symptoms >1 month Children, adolescents, young adults with pre-existing mental health issues or migraine headaches also likely at risk for persistent symptoms >1 month ADHD, learning disabilities may require more help with academic accommodations during recovery but have not been shown to be at increased risk for persistent symptoms overall Teenage years (high school age) have been shown to be at greater risk for persistent symptoms. Females>Males Lots of different modalities (MRI, DTI, MRS, HR, fluid biomarkers, etc) to measure physiologic recovery exist but none have the ability to define a single physiologic timeframe to recovery. Studies do suggest physiologic recovery outlasts clinical recovery which supports gradual return with “buffer zone” integrated.

Recover While many studies have tried to show a correlation between injury severity characteristics and greater acute effects or prolonged recovery, results have been inconclusive Post injury clinical factors (severity of cognitive deficits, post traumatic headache or migraine, dizziness, oculomotor dysfunction, depression) have been shown to be associated with worse outcomes Low level of symptoms the day after the injury has been shown as a favorable predictor for recovery

Return to sport (RTS) Graduated stepwise rehabilitation strategy Note: An initial period of 24–48 hours of both relative physical rest and cognitive rest is recommended before beginning the RTS progression. There should be at least 24 hours (or longer) for each step of the progression. If any symptoms worsen during exercise, the athlete should go back to the previous step. Resistance training should be added only in the later stages (stage 3 or 4 at the earliest). If symptoms are persistent (e.g., more than 10–14 days in adults or more than 1 month in children), the athlete should be referred to a healthcare professional who is an expert in the management of concussion.

Return to sport

Reconsider (special populations) No difference in recommendations for management based on skill level of athlete Treatment recommendations are designed to be applied to athletes age 18 and older. Child and adolescent guidelines are for athletes age 18 and younger (Child 5-12 yr, adolescent 12-18 yr). Need more research into specific nuances applicable to these age populations. Children and adolescents shouldn’t return to sport until they have returned to school, but early introduction of symptom limited light activity is appropriate. Schools should have SRC policy in place including education to teachers, staff, students and parents with appropriate academic accommodations and support

Reconsider-Return to school Stage Aim Activity Goal 1 Daily activities at home that do not give the child symptoms Typical activities of the child during the day as long as they do not increase symptoms (eg, reading, texting, screen time). Start with 5–15 min at a time and gradually build up Gradual return to typical activities 2 School Activities Homework, reading or other cognitive activities outside of the classroom Increase tolerance to cognitive work 3 Return to school part time Gradual introduction of schoolwork. May need to start with a partial school day or with increased breaks during the day Increase academic activities 4 Return to school full time Gradually progress school activities until a full day can be tolerated Return to full academic activities and catch up on missed work

Residual effects and sequelae The literature on neurobehavioral sequelae and long-term consequences of exposure to recurrent head trauma is inconsistent. Clinicians need to be mindful of the potential for long-term problems such as cognitive impairment, depression, etc in the management of all athletes Need to keep in mind CTE as potential sequelae though cause and effect relationship has not been clearly established

Risk reduction Detailed SRC history is important because it offers the opportunity to identify high risk athlete (for injury and poor recovery) and it provides an opportunity for concussion education Evidence supports helmet use for ski/snowboard in injury prevention Possible benefit of mouthguard in reducing risk but thus far results in studies are mixed Disallowed body checking in youth hockey (<13yo) has consistently demonstrated decreased incidence of SRC Vision training in collegiate American football may reduce SRC Limiting contact in youth FB decreased head impacts but no evidence that translates into decreased SRC incidence Other rule changes have not shown effect in SRC incidence Rule changes with no effect include: fair play rules in youth hockey, tackle training without equipment in youth FB, tackle training in pro rugby

Risk Reduction Need clear understanding of potentially modifiable risk factors to design studies that will evaluate appropriate prevention interventions for effective risk reduction When considering making rule changes, need to include consideration of impact of those changes not only on concussion incidence but also on psychological and sociocultural aspects of sports Knowledge translation important Treatment is ever evolving and ongoing education is the mainstay of progress in this field

SCAT 3 vs SCAT 5 Tool renumbered to coincide with numerical consensus conference. Reorganized flow of assessment. Immediate on field assessment with red flags listed for consideration of removal from play to further evaluation. Observable signs listed. Maddocks questions unchanged C-spine assessment along with GCS

SCAT 3 vs SCAT 5 Symptom evaluation now includes question about what % of normal do you feel right now and why not if not 100%? Immediate memory includes 10 word recall option, digits backward has 2 trials for each (stop after two negatives) SCAT 5 includes neurological screen Similar update to Child SCAT 5

Conclusion Science of sport related concussion (SRC) is constantly evolving and individual management and return to play decisions remain in the realm of clinical judgment Many areas of research have been identified in the latest consensus meeting and up to date care requires keeping up with new findings as published

References Aubry M , Cantu R , Dvorak J , et al; Concussion in Sport (CIS) Group. Summary and agreement statement of the 1st international symposium on concussion in sport, Vienna 2001. Clin J Sport Med 2002;12:6–11. McCrory P, Johnston K , Meeuwisse W , et al; Summary and agreement statement of the 2nd international conference on concussion in sport, Prague 2004. Br J Sports Med 2005;39:i78–i86. McCrory P , Meeuwisse W , Johnston K , et al; Consensus statement on concussion in sport – the 3rd international conference on concussion in sport held in Zurich, November 2008. Phys Sportsmed 2009;37:141–59. McCrory P, Meeuwisse WH , Aubry M , et al; Consensus statement on concussion in sport: the 4th international conference on concussion in sport held in Zurich, November 2012. Br J Sports Med 2013;47:250–8.

References Meeuwisse WH, Schneider KJ, Dvořák J , et al; The Berlin 2016 process: a summary of methodology for the 5th International Consensus Conference on Concussion in Sport. Br J Sports Med 2017;51:873–876. McCrory P, Meeuwisse W, Dvorak J, et al; Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med 2017;51:838-847. Sport concussion assessment tool - 5th edition. Br J Sports Med 2017;51:851-858. Sport concussion assessment tool for children ages 5 to 12 years. Br J Sports Med 2017;51:862-869.